Basic Information
| Provider Information | |||||||||
| NPI: | 1003181355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC - INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9708 SKILLMAN ST | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752435150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148638064 | ||||||||
| FaxNumber: | 2149321977 | ||||||||
| Practice Location | |||||||||
| Address1: | 9708 SKILLMAN ST | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752435150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148638064 | ||||||||
| FaxNumber: | 2149321977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2012 | ||||||||
| LastUpdateDate: | 03/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 68259 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 68259 | 01 | TX | LPC - INTERN | OTHER |